Surgical versus non-surgical management for patients with malignant bowel obstruction (S1316): a pragmatic comparative effectiveness trial.

BACKGROUND: Malignant small bowel obstruction has a poor prognosis and is associated with multiple related symptoms. The optimal treatment approach is often unclear. We aimed to compare surgical versus non-surgical management with the aim to determine the optimal approach for managing malignant bowel obstruction. METHODS: S1316 was a pragmatic comparative effectiveness trial done within the National Cancer Trials Network at 30 hospital and cancer research centres in the USA, Mexico, Peru, and Colombia. Participants had an intra-abdominal or retroperitoneal primary cancer confirmed via pathological report and malignant bowel disease; were aged 18 years or older with a Zubrod performance status 0-2 within 1 week before admission; had a surgical indication; and treatment equipoise. Participants were randomly assigned (1:1) to surgical or non-surgical treatment using a dynamic balancing algorithm, balancing on primary tumour type. Patients who declined consent for random assignment were offered a prospective observational patient choice pathway. The primary outcome was the number of days alive and out of the hospital (good days) at 91 days. Analyses were based on intention-to-treat linear, logistic, and Cox regression models combining data from both pathways and adjusting for potential confounders. Treatment complications were assessed in all analysed patients in the study. This completed study is registered with ClinicalTrials.gov, NCT02270450. FINDINGS: From May 11, 2015, to April 27, 2020, 221 patients were enrolled (143 [65%] were female and 78 [35%] were male). There were 199 evaluable participants: 49 in the randomised pathway (24 surgery and 25 non-surgery) and 150 in the patient choice pathway (58 surgery and 92 non-surgery). No difference was seen between surgery and non-surgery for the primary outcome of good days: mean 42·6 days (SD 32·2) in the randomised surgery group, 43·9 days (29·5) in the randomised non-surgery group, 54·8 days (27·0) in the patient choice surgery group, and 52·7 days (30·7) in the patient choice non-surgery group (adjusted mean difference 2·9 additional good days in surgical versus non-surgical treatment [95% CI -5·5 to 11·3]; p=0·50). During their initial hospital stay, six participants died, five due to cancer progression (four patients from the randomised pathway, two in each treatment group, and one from the patient choice pathway, in the surgery group) and one due to malignant bowel obstruction treatment complications (patient choice pathway, non-surgery). The most common grade 3-4 malignant bowel obstruction treatment complication was anaemia (three [6%] patients in the randomised pathway, all in the surgical group, and five [3%] patients in the patient choice pathway, four in the surgical group and one in the non-surgical group). INTERPRETATION: In our study, whether patients received a surgical or non-surgical treatment approach did not influence good days during the first 91 days after registration. These findings should inform treatment decisions for patients hospitalised with malignant bowel obstruction. FUNDING: Agency for Healthcare Research and Quality and the National Cancer Institute. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

Benchmarks and Geographic Differences in Gallbladder Cancer Surgery: An International Multicenter Study.

BACKGROUND: High-quality surgery plays a central role in the delivery of excellent oncologic care. Benchmark values indicate the best achievable results. We aimed to define benchmark values for gallbladder cancer (GBC) surgery across an international population. PATIENTS AND METHODS: This study included consecutive patients with GBC who underwent curative-intent surgery during 2000-2021 at 13 centers, across seven countries and four continents. Patients operated on at high-volume centers without the need for vascular and/or bile duct reconstruction and without significant comorbidities were chosen as the benchmark group. RESULTS: Of 906 patients who underwent curative-intent GBC surgery during the study period, 245 (27%) were included in the benchmark group. These were predominantly women (n = 174, 71%) and had a median age of 64 years (interquartile range 57-70 years). In the benchmark group, 50 patients (20%) experienced complications within 90 days after surgery, with 20 patients (8%) developing major complications (Clavien-Dindo grade ≥ IIIa). Median length of postoperative hospital stay was 6 days (interquartile range 4-8 days). Benchmark values included ≥ 4 lymph nodes retrieved, estimated intraoperative blood loss ≤ 350 mL, perioperative blood transfusion rate ≤ 13%, operative time ≤ 332 min, length of hospital stay ≤ 8 days, R1 margin rate ≤ 7%, complication rate ≤ 22%, and rate of grade ≥ IIIa complications ≤ 11%. CONCLUSIONS: Surgery for GBC remains associated with significant morbidity. The availability of benchmark values may facilitate comparisons in future analyses among GBC patients, GBC surgical approaches, and centers performing GBC surgery.

Mammea B/BA Isolated From the Seeds of Mammea americana L. (Calophyllaceae) is a Potent Inhibitor of Methicillin-Resistant Staphylococcus aureus.

Staphylococcus aureus remains a pathogen of high concern in public health programs worldwide due to antibiotic resistance and emergence of highly virulent strains. Many phytochemicals have demonstrated activity against S. aureus and other Gram-positive bacteria, but the minimum inhibitory concentration (MIC) values comparable to commonly used antibiotics are needed. In the present study, bio-guided fractionation of the ethanol extract of seeds of Mammea americana L. (Calophyllaceae) throughout the antibacterial activity, against S. aureus strains that are sensitive and resistant to methicillin, led to the isolation of four coumarins identified as mammea B/BA, mammea B/BC, mammea A/AA cyclo D and mammea A/AA cyclo F, and a mixture of mammea B/BA cyclo F plus mammea B/BD cyclo F. The extract inhibited the growth of S. aureus with MIC values of 2-4 µg/ml and Mammea B/BA (MaBBA) presented MIC values in a range between 0.5 and 1.0 µg/ml in six methicillin-sensitive strains and eight methicillin-resistant strains evaluated. We consider MaBBA the most potent of all mammea coumarins reported to date, according to the literature review carried out at the time of writing of this article. Toxicity assessment in vivo against the nematode Caenorhabditis elegans and in vitro against human fibroblasts of the extract and the compound MaBBA indicated that both had low toxicity.

Síndrome de Kounis, a propósito de un caso / Kounis syndrome, apropos of a case

El síndrome de Kounis se caracteriza por un compromiso cardiaco que es secundario a una respuesta alérgica. Hay pocos datos acerca de la epidemiologia de esta enfermedad debido a su reciente descripción. Se presenta el caso de una paciente mujer de 46 años sin antecedentes de importancia que presentó dolor tipo cólico episódico en hipocondrio derecho de 4 días de tiempo de enfermedad, en la que se consideró el diagnóstico de cólico de origen biliar. Quince minutos luego de manejo sintomático (hiocsina/dipirona), la paciente presentó dolor torácico en región precordial de inicio súbito. La evaluación física mostró hipotensión, taquicardia, presencia de habones en todo el cuerpo y sibilantes a la auscultación pulmonar. El electrocardiograma mostro infradesnivel del segmento ST. Considerado como síndrome coronario agudo, se realizó el manejo con esteroides y soporte vital, y se indicó monitorización cardiovascular en unidad de cuidados intensivos. La paciente egresó sin complicación luego de unos días

Kounis syndrome is defined as an acute coronary syndrome secondary to an allergic response; and it is also known as allergic angina - acute myocardial infarction. There is little data on the epidemiology of this disease because of having been recently described. We present the case of a 46-year old woman who developed an episode of colicky abdominal pain in the right upper quadrant for 4 days, and a diagnosis of abdominal pain of biliary origin was considered. Fifteen minutes after symptomatic therapy was administered (hyoscine and metamizole), the patient developed sudden chest pain. Physical examination revealed hypotension, tachycardia, rash, and wheezing. The electrocardiogram showed ST segment depression. The case was managed as an acute coronary syndrome, vital support and steroids were part of its management, and the patient was admitted in the intensive care unit for coronary monitoring. A few days later, the patient was uneventfully discharged

Unplanned reoperations: is emergency surgery a risk factor? A cohort study.

BACKGROUND: Unplanned reoperations have been proposed as a quality indicator in surgery but have not been studied extensively, especially concerning risk factors. METHODS: This was a prospective cohort study in a third-level general surgery service. Data regarding patients operated on between July 2007 and February 2008 and followed up for 30 postoperative days were collected. Unplanned reoperations were the primary end point. The secondary end points were 30-d mortality and length of stay. A multivariate logistic regression analysis evaluated the hypothesis that patients operated on in emergency conditions had a greater chance of being reoperated on, after adjusting for relevant covariates. RESULTS: There was a 5.9% cumulative incidence of unplanned reoperations. Patients operated on in emergency conditions had a 1.79 crude relative risk (RR) (95% confidence interval [CI], 1.15-2.78) of reoperation. Reoperated patients' RR of mortality was 8.94 (95% CI, 6.11-13.07). The mean postoperative hospital stay was 3d for patients who were not reoperated on and 19d for those who were reoperated on (P=0.00001). The logistic regression model gave a 2.83 odds ratio (95% CI, 1.65-4.87) for reoperation on emergency patients when adjusted for age, gender, body mass index, American Society of Anesthesiology classification, intraoperative inotropic use, and operation complexity. CONCLUSIONS: Tertiary general surgery service patients had a significantly increased risk of being reoperated on if the initial surgery was an emergency surgery compared with elective surgery. Unplanned reoperations led to a significantly increased mortality risk and a longer postoperative hospital stay, which could be regarded as warning signs in the care of surgical patients.

Prevalence of flatfoot in school between 3 and 10 years. Study of two different populations geographically and socially / Prevalencia de pie plano en escolares entre 3 y 10 años. Estudio de 2 poblaciones diferentes geográfica y socialmente

Children present with flatfoot from birth and it resolves along infancy. There have been several risk factors identified for the development of flatfoot: male sex, young age, overweight and obesity. The prevalence of flatfoot decreases with age.The aim of this study was to determine the prevalence of flatfoot in two different populations with different social, cultural and geographically characteristics in Colombia.Patients and methods: This is a cross sectional study made on school children between 3 to 10 years of age, from several schools in Bogota and Barranquilla. From 940 total children 60% were from Bogota. Flatfoot was diagnosed according to physical exam.Results: We found a global prevalence of flatfoot of 15.74%, distributed 20,8% in Bogota and 7.9% in Barranquilla. The children from 3 to 5 years had a prevalence of 30,9%, decreasing significantly after this age. It was found that children 3 to 5 years old from Bogota had a prevalence of flatfoot of 38.3% while children from Barranquilla only 17.3%, decreasing significantly in children older than 6 years. In the multivariate analysis we found an association between flatfoot with age, city, gender and body mass index.Discussion: We found a bigger prevalence of flatfoot in the population of Bogota compared to Barranquilla suggesting an influence of social, cultural and racial factors in the development of flatfoot. The diminished prevalence of flatfoot in children over 6 years of age suggest that therapeutic measures before this age are not recommended

Prevalence of flatfoot in school between 3 and 10 years. Study of two different populations geographically and socially.

INTRODUCTION: Children present with flatfoot from birth and it resolves along infancy. There have been several risk factors identified for the development of flatfoot: male sex, young age, overweight and obesity. The prevalence of flatfoot decreases with age. The aim of this study was to determine the prevalence of flatfoot in two different populations with different social, cultural and geographically characteristics in Colombia. METHODS: This is a cross sectional study made on school children between 3 to 10 years of age, from several schools in Bogota and Barranquilla. From 940 total children 60% were from Bogota. Flatfoot was diagnosed according to physical exam. RESULTS: We found a global prevalence of flatfoot of 15.7%, distributed 20.8% in Bogota and 7.9% in Barranquilla. The children from 3 to 5 years had a prevalence of 30.9%, decreasing significantly after this age. It was found that children 3 to 5 years old from Bogota had a prevalence of flatfoot of 38.3% while children from Barranquilla only 17.3%, decreasing significantly in children older than 6 years. In the multivariate analysis we found an association between flatfoot with age, city, gender and body mass index. DISCUSSION: We found a bigger prevalence of flatfoot in the population of Bogota compared to Barranquilla suggesting an influence of social, cultural and racial factors in the development of flatfoot. The diminished prevalence of flatfoot in children over 6 years of age suggest that therapeutic measures before this age are not recommended.

INTRODUCCIÓN: Los niños presentan el arco plantar plano al nacimiento, el cual se desarrolla durante la primera década de la vida. Han sido identificados como factores de riesgo para pie plano: el sexo masculino, menor edad, el sobrepeso y la obesidad. La prevalencia del pie plano disminuye con la edad. El objetivo general del estudio es determinar la prevalencia del pie plano en dos poblaciones diferentes desde el punto de vista geográfico, cultural y social en Colombia. MÉTODOS: Es un estudio de prevalencia, de corte transversal, realizado en niños entre 3 y 10 años, estudiantes de colegios de Bogotá y Barranquilla. Se evaluaron 940 niños, 60% en la ciudad de Bogotá. Se determinó el pie plano mediante el examen físico. RESULTADOS: Se encontró una prevalencia global de pie plano de 15.7%, en Bogotá de 20.8% y en Barranquilla 7.9%. Los niños en el rango de 3 a 5 años tuvieron una prevalencia de 30.9%, disminuyendo de forma significativa después de esta edad. Se encontró que los niños de Bogotá entre 3 y 5 años tenían una prevalencia de pie plano de 38.3 % y los de Barranquilla tan solo 17.3 %, disminuyendo significativamente en los mayores de 6 años. En el análisis multivariable se encontró asociado el pie plano con la edad, ciudad, género y el índice de masa corporal. DISCUSIÓN: Se tuvo una mayor prevalencia en Bogotá comparada con Barranquilla en las poblaciones estudiadas sugiriendo la influencia de factores culturales, sociales y raciales en la aparición de pie plano. El descenso importante en la prevalencia en los mayores de 6 años, sugiere limitar el uso de medidas terapéuticas antes de esta edad.